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CYSTIC FIBROSIS SERVICES, LLC
CAH461303-00 IHC Health Services INC dba INTERMOUNTAIN HEALTH SANPETE VALLEY HOSPITAL
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Covered Entity Details
Entity Name
IHC Health Services INC dba INTERMOUNTAIN HEALTH SANPETE VALLEY HOSPITAL
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH461303-00
Entity Address
1100 SOUTH MEDICAL DRIVE
MT. PLEASANT, UT 84647
Medicare Provider Number
461303
Participating Start Date
10/1/2014
Last Recertification Date
8/13/2024
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
10/15/2018
Contract Begin Date
1/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/7/2020
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Aaron Wood, CEO/Administrator-Sanpete
(435) 462-4123
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
10/15/2018
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